White Rock Medical Center LLC-posted 4 months ago
Full-time • Mid Level
Dallas, TX
1,001-5,000 employees

White Rock Medical Center is a community-based hospital located near the historic White Rock Lake community, that serves the Dallas, Garland, Mesquite and surrounding areas. We specialize in a wide range of services including comprehensive medical/surgical care, bariatric, cardiology, outpatient and emergency medicine. Our mission is to deliver exceptional healthcare with compassion and excellence. White Rock Medical Center is seeking compassionate, care-minded individuals to join our company and make a difference. As a member of the White Rock Medical Center team, you can advance your skills while working in a supportive and patient focused environment. Apply today!

  • Monitor, track, and analyze quality and patient safety data, including core measures, infection prevention indicators, adverse events, and regulatory metrics.
  • Assist in developing, implementing, and evaluating performance improvement (PI) projects.
  • Support the hospital’s peer review, mortality review, and quality council processes.
  • Educate staff and leadership on quality initiatives, best practices, and patient safety culture.
  • Maintain continuous readiness for CIHQ/Joint Commission, CMS, and state regulatory surveys.
  • Conduct tracer rounds, audits, and Environment of Care (EOC) rounds across clinical and non-clinical departments to identify and correct compliance gaps.
  • Provide coaching and education to staff and leaders on regulatory requirements and best practices.
  • Assist with policy review and development to ensure alignment with accreditation and regulatory requirements.
  • Maintain records, logs, and documentation for survey readiness and accreditation activities.
  • Collect, validate, and submit quality reporting data to CMS, NHSN, CIHQ, state agencies, and other regulatory bodies as required.
  • Generate and maintain quality dashboards and scorecards for leadership, quality committees, and the governing body.
  • Monitor hospital performance against benchmarks, patient safety goals, and regulatory indicators.
  • Participate in root cause analyses (RCA) and assist in action plan development and follow-up.
  • Partner with nursing, physicians, infection prevention, risk management, facilities/plant operations, and other hospital leaders to drive improvement efforts.
  • Provide real-time feedback and coaching during rounds and audits.
  • Support hospital staff education related to quality, patient safety, environment of care, and regulatory standards.
  • Graduate of an accredited school of nursing; BSN preferred.
  • Minimum 3 years of clinical nursing experience in an acute care hospital required.
  • Experience in quality, patient safety, accreditation, or regulatory compliance preferred.
  • Experience with CMS reporting requirements, NHSN surveillance and data entry, and hospital quality data reporting strongly preferred.
  • Current, unrestricted RN license in the State of Texas (or compact state).
  • Certified Professional in Healthcare Quality (CPHQ) preferred or obtained within 2 years of hire.
  • Strong knowledge of CIHQ/Joint Commission standards, CMS Conditions of Participation, and state regulatory requirements.
  • Working knowledge of Environment of Care (EOC) standards across both clinical and non-clinical departments.
  • Strong background in quality reporting, NHSN surveillance, CMS measure submission, and regulatory data validation.
  • Excellent organizational and time-management skills with attention to detail.
  • Strong analytical skills with ability to interpret and present data to leadership.
  • Proficiency with Microsoft Office Suite, NHSN portals, CMS QualityNet, and quality data systems.
  • Effective communication and interpersonal skills for working with physicians, staff, and leadership.
  • Ability to function independently while collaborating in a team environment.
  • Experience in quality, patient safety, accreditation, or regulatory compliance preferred.
  • Certified Professional in Healthcare Quality (CPHQ) preferred or obtained within 2 years of hire.
  • Competitive salary and benefits/Company 401(k)
  • Employee programs and events.
  • Paid Time Off and 7 Company Holidays.
  • Employer paid life insurance.
  • Additional voluntary benefits such as STD, LTD, etc.
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